Over the last few days, it has repeatedly been said to me that the police have a lot, if not too much, to say on mental health issues. “Mental health is not the business of the police” said one commentator. (I know that Lord ADEBOWALE would disagree with them, to name just one prominent personage!) During “Any Other Business” in a meeting, a colleague reported that everyone except the police representative was asked if there was anything they wanted to add before conclusion. “Why not the police?”, enquiried a health professional? “I think they’ve said enough already.” replied the chair. I also had feedback during my hiatus, that although my efforts are welcomed, we need to see more mental health professionals pushing the agenda on social media, too arguing for improvements and for parity across our health and social care systems.
I completely and unequivocally agree.
Our police service know quite a lot about mental ill-health in our society, whether or not they realise it and this is especially true of crisis care. The police have data on missing people, a good proportion of which includes absentees from institutional care. The police have a lot of information on those coming through police custody which will include information on suspects and others experiencing mental distress. The police encounter people in particular kinds of circumstances which can often tell us a lot about how local services work, it tells us all about forms of social exclusion, inability to access a GP or difficulty penetrating the web of commissioning arrangements in our health system.
So why aren’t we exploiting that at all levels? The police service are not a statutory part of Health and Wellbeing Boards – whether or not a Chief Constable, a local police commander or even an elected Police and Crime Commissioner is able to access that crucial local forum is dependent upon the views of statutory members. And I’m struggling to wonder what the police know about mental disorder and social exclusion that would not help such local arrangements, especially given that health and other statutory services are already linked in law to a mutual agenda through Crime and Disorder Reduction / Community Safety Partnerships.
DRIVING THE AGENDA
It seems somewhat inevitable over the last few years that the police service would wake up to the increasing reality that mental health demands are forming a greater part of their role. Things that NEVER occurred when I served as a police constable became unremarkable when I was a sergeant and have become routine now that I’m an inspector. We’ve seen the police service come under very considerable scrutiny during my service for very serious events – the most serious – connected to mental ill-health. The reputation of British policing is very genuinely scarred by those experiences and for many people, trust in the police is irreversibly damaged. The highest level of inquiry and investigation has occured into the most high-profile of these matters from Coronial Inquests to Commissions of Inquiry like that chaired by Lord ADEBOWALE.
So it seems inevitable to me that the discussion that we know goes on in police stations would translate eventually to a very real effort to influence the agenda at all levels. Frontline police officers, questioning or even resisting some of the things they are now asked to do. Local commanders and Chief Constables investing some of their resources to develop their tactical and operational responses on improving local protocols with health organisations, and developing initiatives like Liaison & Diversion and Street Triage. We also know that senior representatives of the service as a whole have made their views known to Government through the statutory inspectorates and ACPO. The new College of Policing is working on improving the guidelines which support the development of these initiatives and the training which officers, hopefully at all levels, can receive.
But how far is too far; how much is too much? The police are not and never will be mental health experts. And we are certainly not experts in knowing what those of us who live with mental disorders may feel they want or need – the police, with their “Do Something!” mentality, need to be very cautious about paternalism. So when I first got interested, it seemed to me that the police needed to understand what mainstream services thought that patients in mental distress needed and support that process unquestionably. We have a first world psychiatric system which, despite its faults, represents considerable investment in the possibility of care and support compared to a lot of other countries. So it came as quite a shock to me as my learning developed, to understand that this may be making things worse, not better.
QUESTIONING THE AGENDA
The police and others are poised to make significant decisions about how to invest newly available resources and how to address decades old issues that have been causing increasing concern. So it seems fair to expect us to think about how these agenda will develop. We see debate recently about Street Triage, for example: originally conceived as mental health nurses paired with police officers. But why not pair them with an AMHP instead? – certainly several AMHPs have questioned the instigation of processes that remove what is still predominantly a role for mental health social work in supporting the police. After all, many people will very quickly point out that most people detained by the police under 136 of the Mental Health Act are not subsequently admitted to hospital because of an acute medical condition. 83% of those detained are offered forms of support in the community where social issues are potentially as important if not more so than psychiatric problems. So how does that viewpoint affect the triage concept, if at all? This is certainly what one area of England, at least, is thinking of doing.
Of course, some might argue that the broader model of mental health care is questionable: The Division of Clinical Psychology from the British Psychological Association issued a position statement in 2013 which questioned the whole nature of medical diagnosis. How does that debate affect the decisions that we make in the criminal justice system about responses to mental distress? If I’ve learned anything in what is now ten active years of interest, reading and working in this area, it is that it does affect it. We know, for example, that we talk very freely of the benefits of liaison and diversion for offenders with unmet mental health needs. But when you look hard for it, there isn’t actually any proper research that looks at long-term outcomes for both recovery AND re-offending. Where we have seen people who have offended at least twice in situations where they are unwell, we haven’t fully deconstructed how decisions are made about diversion and what those decisions then mean for the prospects of recovery and rehabilitation. I’ve written before about how some offending is casued by problems of mental ill-health and how other offending is actually quite incidental. We rarely seek to understand this, despite its obvious implications for how we structure the services that we are on the verge of investing millions in.
We also know that the criminal justice system itself is not designed with the preservation of mental wellbeing primarily in mind. Those who have worked in the prison system or even those of us who have been inside prisons, can easily understand how having ones life halted by a conviction and imprisonment could contribute massively to the aggravation of existing mental health problems or play a significant part in causing them – but that is not necessarily a reason not to prosecute someone, because the public interest in a prosecution for very serious matters may be very high indeed and imprisonment may be regrettably necessary. Jill PEAY first drew this perfectly obvious point to my attention in her book Mental Health and Crime (2010) – I would advise everybody to read this book, because it actually gets into the detail of the argument that both “mental illness” and “mentally disordered offenders” are quite artificial concepts that survive attempts to define them. What, exactly, is a “mentally disordered offender”- and therefore how do we know who is in and out of schemes designed to support them?
WHAT ARE WE TRYING TO ACHIEVE?
Whatever the answers to those questions and more philosophical ones about how we reconcile an essentially categorical system like criminal justice with a consequentialist one like health, all I do know is that the police have got a shed load of data and an insight into these issues that few health professionals share.
Add to that a very different operating culture (which I can assure has positive aspects!) and an entirely different perspective. This offers at least something to those senior leaders in health who are seeking to understand how an agenda for change in the provision of care is being pointed towards them.
The police have got a lot to say about mental health because of a unique perspective on it so my advice to those who think we shout too loudly and talk too much would be: to ask yourself why?
Winner of the Mind Digital Media Award.